Medically Unexplained Symptoms

Medically Unexplained Symptoms

 ‘The trouble with the world is that the stupid are so confident while the intelligent are full of doubt.’ Bertrand Russell

 It always seems so ironic to me that medical training is still centred around disease and objective pathology, yet clinical practice is entirely based around symptoms and subjective experience. We spend much of our working day dealing with symptoms for which there is no explanation, floundering around in the no-man’s land between patients’ hopes (of an explanation and cure) and what we are trained to do (to rule pathology in or out). We are left with a continuing unexplained symptom, frustrated patient and tired doctor. Into this void move the snake-oil peddlers, ready to exploit human need for certainty, for explanation and for cure.  Recognising and managing MUS better would be a great thing to develop on your PDP over the next year, to have some practice training on or as a tutorial subject. Fortunately there are some great resources out there to help us.

ð What is the scale of the problem

Enormous!!! Recent guidelines (referenced below) suggest that

·       Between 20% to 30% of consultations in primary care are due to MUS

·      Patients with MUS also take up 40% of medical outpatient clinics, with enormous associated costs, iatrogenic harm and no benefit

·       Although the term ‘somatisation’ is unpopular with patients, up to 70% of patients with MUS do also suffer from depression and/or anxiety and in particular have high levels of health anxiety

·       The research suggests that people are willing to accept that psychological factors may be causing the MUS as long as we as doctors keep an open mind. There is also an association with childhood adversity and abuse.

 ð How do we recognise MUS?

This is the easy bit! Physical symptoms with no clear explanation which have gone on for at least 3 months and affect functioning is the usual definition. If you like using questionnaire scores, the PHQ-15 score has been validated to help identify patients with somatisation disorder  www.iapt.nhs.uk/silo/files/phq15.doc

 ð What guidance is out there to help me manage these patients?

ΠExcellent guidelines for GPs for MUS were developed in 2011 by the Forum for Mental Health in Primary Care, hosted by the RCGP and RCPsych.

http://www.nmhdu.org.uk/silo/files/guidance-for-health-professionals-on-medically-unexplained-symptoms-mus.pdf

They stress that the only therapy that may be needed is the strength of the doctor patient relationship and continuity of care. Many patients just need reassurance, a simple explanation that makes sense and removes any blame from the patient and generates ideas about how to manage symptoms and improve function. Key learning points are:

·      People need to be taken seriously. Showing patients we believe them is crucial.

·      Concentrate on managing symptoms and improving function. Treat the treatable (e.g. associated depression, better pain control) and refer for physical therapies to improve function.  Recognise that MUS can also contribute towards impaired function in physical disease as well e.g. 60% of people with lung symptoms hyperventilate.

·      Be pre-emptively reassuring, yet keep an open mind and be willing to re-assess. Most MUS do resolve. 25% in primary care persist at 12 months.

·       Not investigating may be the best option for the patient. Investigating can give the impression we think something is wrong. If you expect the result to be normal, share that at the outset. When referring and investigating pre-empt normal results, and be very clear on the reason for the referral/investigation (eg to exclude significant pathology)

·      Enforcing psychosocial explanations will not work as it encourages defensiveness. Allowing time and encouraging the patient to make connections is much more effective.  The ‘reattribution model’ (Goldberg & Gask) is encouraged

o   Make the patient feel understood

o   Broaden the agenda

o   Negotiate a new understanding of symptoms , including psychosocial factors

  Psychological therapies. IAPT Guidance

The evidence base is good that CBT helps MUS. In the NHS the Improving Access to Psychological Therapies programme have produced a positive practice guide for MUS, strongly recommending commissioners to commission services and to encourage GPs to refer for MUS.

http://www.iapt.nhs.uk/silo/files/medically-unexplained-symptoms-positive-practice-guide.pdf

 Ž Functional symptoms

The RCGP guide encourages us not to give a diagnosis whatever, but to talk about functional conditions and being able to manage symptoms. Neurosymptoms is an excellent self-help web-site on functional symptoms, written by a neurologist with a special interest in MUS

http://www.neurosymptoms.org/

 ðBut, I had a patient with MUS who then turned out to have Addison’s disease?

 We all have these cases, and living with this uncertainty and seeing how things evolve over time is of course central to general practice. Long-term follow up studies suggest that 4 to 10% of this patient group go on to have an organic explanation for their symptoms. Keep an open mind and be willing to re-assess.

 ð What about at a commissioning level?

Patients with MUS use up huge amounts of NHS resources. With an estimated annual cost of £3billion to the NHS, this is an area worth investing some cash! GPs with their holistic knowledge of the patient, their finely honed communication skills and their central role in co-ordinating care are the ideal people to manage MUS. CBT is the intervention most shown to work. A recent pilot project suggests that referring patients with MUS to a primary care, GP led symptoms clinic to see a GP with CBT training and dedicated, longer appointments is feasible and may improve outcomes. I would love to see a GP led clinic like this I could refer patients to and indeed would even be interested in working in one should it appear!

 http://bmjopen.bmj.com/content/2/1/e000513.full

Conclusion: Recognition and management of MUS is part of what makes General Practice so fascinating, and yet also so challenging. These resources can help us rise to this challenge to help patients. If you have any other good tips or resources do please share!

 Simon

NB Since this blog there have been new evidence-based guidelines on MUS published, see

Dutch College of GPs MUS Guideline 2013 (English version)